| NPI | 1083888028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NC 0111) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MD 06926) |
| Enumeration Date | 2008-04-22 |
| Last Update Date | 2012-10-09 |